Telemedicine: Possibilities and Issues This is a paper regarding the use of communication technology in medicine and healthcare. The Issue is telemedicine, and the article related to is given in the reference.

The possibility, practicality and the desirability of the use of communication technologies are discussed and the issues in telemedicine identified. It is recommended that the issues be researched further and the implications, technical and medico legal sorted out side by side with the use of information and communication technologies in medicine.

The benefits of telemedicine can be enormous, and even save money in many cases, but there is also the potential for medico legal implications and the danger of excessive dependence on the machine rather than the man in the use of telemedicine. Overall, it is potentially a highly beneficial field provided it is driven by patient and healthcare needs rather than driven by the profit motive of the IT and communication industries.

Introduction

Enrico Coiera, project manager a Hewlett-Packard Research Laboratories, Stoke Gifford, Bristol has discussed the use of new information technologies in medical informatics and raised the issues pertinent to it in his article "Recent Advances: Medical informatics" in BMJ 1995;310:1381-1387 (27 May). The article summarizes the developments in the field of medical informatics and then discusses the motivation behind and the issues concerned with the application of technology. Any attempt that are motivated by use of technology for its own sake rather than for tailor it to the needs of the healthcare systems are bound to fail.

The growing use of Telemedicine

He acknowledges that the use of the information sciences in medicine is growing and is expected to continues to grow. The scope is enormous. It finds use in:

1. The design of decision support systems for practitioners

2. The development of computer tools for research,

3. The study of the very essence of medicine -- its corpus of knowledge.

His forecast is that the use of informatics in the next [21st] century will probably be as fundamental to the practice of medicine as the study of anatomy has been in the 20th century.

He matches the advances in medical informatics with apparently unbridled technological promise against unsatisfactory practical achievement. His criteria for this are:

1. Possibility, -- which reflects what in theory can be achieved in the field of medicine and healthcare by information technology?

2. Practicability, -- which addresses the potential for successfully engineering a system keeping in mind the constraints of the real world, and

3. Desirability -- which looks at the fundamental motivation for using a given technology.

The Need for a Framework

He suggests these criteria because according to him "a framework is necessary to judge the claims made for the new technologies by those who seek to profit from them." (Coiera, Enrico, 1995) An interdependence is developing between the information technology and medicine fields similar to one that already exists between the pharmaceutical and medical fields.

A parallel is drawn between the IT industry and the pharmaceutical in another way: judging the claims made by the new technologies in the same way as the claims of new drug manufacturers are judged. But here one may add that the claims of the drugs are judged based on analyses of research by medical and healthcare practitioners and associated academia as well as the drug agencies, and institutions under government control. A similar research-based system would be necessary to judge the claims of the IT practitioners and the IT industry. He rightly stresses that this is even more necessary for the IT field because contrary to the pharmaceutical field about which medical and health personnel are fairly knowledgeable, they are not so knowledgeable about informatics and telecommunications.

The three areas discussed by the author encompass telemedicine, in which research themes are just becoming apparent, protocol-based decision support systems, which may be the first substantive clinical information systems to appear in routine clinical practice, and the current state of clinical coding and terminology. The last seeks to describe uniformly the structure, content, and nature of medical knowledge.

These three -- telemedicine, protocol-based decision support systems...

This is fundamentally linked to the human communication process as the context is very important in this process to an understanding of what is being communicated.
The Essence of Telemedicine

The essence of telemedicine is the exchange of information at a distance, whether by voice, an image, elements of a medical record, or commands to a surgical robot. It is not a new enterprise, as formerly telephone has been used. The advances in IT increase the possibilities tremendously. What should be understood is that:

1. The application of information and communication technologies in health care should be driven by concern for solving problems rather than be technology driven

2. The use of existing communication technologies such as mobile telephones, voice mail, and email may significantly improve delivery of health care

3. Research is needed to understand human communication processes and needs in health care

4. Clinical information systems have an important role in the delivery of evidence-based clinical practice

5. The appropriate use of computerized protocols can significantly improve clinical outcome

6. Universal and complete clinical coding schemes are unrealizable, and the continued modification of centralized thesauruses may be technically and financially unsustainable

7. Multiple task specific terminologies developed in conjunction with clinical protocols may offer the most effective and maintainable long-term strategy

The health care system is clearly inefficient because of its poor communication infrastructure and telemedicine is now seen as a critical way of reducing that cost. One estimate suggests that the health system in the United States could save $30 billion a year with improved telecommunications.(Coiera, Enrico, 1995)

The evolving options in telecommunications market are numerous -- cable television, mobile cellular carriers, and telecommunication companies. Communications technology does not even need to be sophisticated to deliver benefit. Appropriate use of telephone, for example, can make significant improvements to the delivery of care in such areas, say, as follow up of patients.

Research Issues in Telemedicine

The author has identified several issues related to telemedicine. The issues of confidentiality and security, as well as of storage and retrieval of voice recordings and other information when required are new issues peculiar to telemedicine. Also, besides the issue of retrieval is the issue of how to decide which information is important

The second group o issues is the people's understanding of the effects of technology on communication. Researchers in human-computer interaction believe that before communication technologies can be gainfully introduced, the way in which people communicate needs to be understood. In one recent study it was found that the doctors paid more attention to the computer screen than the patient during patient consultation. Their response to the patient were also short and delayed. There may also be the tendency to over-rate the ability of the computer and protocols in diagnosis and other areas.

The positive side is the value of the computer in remote telemedical consultations. Also the general practitioners gained by repeated interactions with specialists through computer-based communication. Unlike educational settings, both are motivated to form a coach and apprentice relationship for the immediate management of a patient.

Probably the most important issue for researchers is to understand the effect of introducing technologies that allow asynchronous [non-simultaneous] communication. Synchronous devices such as telephones interrupt people when communication is desired. asynchronous systems such as e-mail and voice mail do not need to be answered immediately and reduce the number of interruptions experienced by clinicians. It will be critical to understand how such systems can be designed to ensure that health care workers do not miss important information while at the same time are not inundated with irrelevant messages.

Medico-legal implications are also another important area that needs research. In the U.S., radiologists are deemed by law to be negligent if they fail to inform clinicians personally of a diagnosis. These issues have to…